Patients (middle-high or high social and economic class) were examined at a private dental office specialized in periodontology and dental implantology. They were already oriented to receiving dental implants as a replacement therapy as part of their periodontal and restorative treatments. Patients were considered who had not received any bone grafts, soft tissue grafts, sinus floor elevation, or nerve transposition procedures before implant placement in the last 3 years. In the 75 patients selected at random, a total of 221 implants had been placed.
As psychological preparation, all the patients received only the necessary explanations about dental implants. Questions, typically asked at this point, were answered by the clinicians. These questions included the following: What is an implant?, What do they look like?, How will the surgery be performed?, How many surgeries are involved?, Are they painful?, Will I have pain after surgery?, Can I work immediately after surgery?, How will my private life be affected?, Will I be able to swallow?, How and when am I going to be restored?, How am I going to look?, How long is the treatment going to take?, How much will the treatment cost? And, of course, How long are they going to last?
The use of the necessary didactic materials, the availability of printed material to read, and bringing the patients in contact with other patients who have already had the experiences were crucial aids to our explanations and to create a better understanding for the patients and to assure them about the simplicity of the procedures and the absence of pain.
Once the patient’s confidence had been established about the proposed therapy, the letter of consent was signed. Each patient was examined according to a specially designed Pain Data Sheet, following the protocol oriented to analyze the individual threshold to pain. Presurgical and postsurgical instructions were standard for all patients. The pain data sheets were filled out by two independent clinicians who evaluated all signs and symptoms. The clinicians were trained and qualified by the surgeon. They had to transform subjective data to numerical data.

Data Records.

• Phase I: 2 Days before surgery.
  Recorded data included age group and gender; the fear of the dentist and the fear of implantology as measured on a scale from 1 (no fear) to 10 (maximum fear); whether the pa tient was partially or totally edentulous; the presence or absence of temporomandibular myofascial pain disorders, recorded as yes or no; and buccal opening, recorded in millimeters. Function and pain were recorded for swallowing, talking, yawning, opening, closing, lateral movements, neck pain, and back pain as present or absent. Palpation and pain for the temporomandibular joint, temporal muscles, medial and external pterygoid muscles, and masseter muscles were recorded as present or absent. Dentate areas and ridges, dental pain, edentulous areas, and implanted areas were recorded using a pain scale measuring from 0 to 8: 0, no pain; 1, discomfort that does not reach the level of pain; 2, sporadic or intermittent pain; 3, continuous pain; 4, strong persistent pain that requires pain medication; 5, pain only controllable with pain medication; 6, recurring strong pain; 7, remission pain; and 8, periodic pain.
  Pain in dentate areas and edentulous areas as well as other important symptoms that the patient described at the time of examination such as ear pain, neuralgia, cephalalgia, postoperative edema, and hematoma were evaluated and recorded. Previous dental experiences were recorded as good or bad. The same presurgical medication was given to all patients according to the protocol. All of the parameters were recorded during an appointment 2 days before surgery.
• Phase II: Surgery.
  Surgery was performed under local anesthesia (lidocaine 2% with epinephrine 1:100,000) according to a modified Brånemark surgical protocol. Standard screw-type implants (Restore, Lifecore Biomedical) were utilized in the mandible, and cylindrical pressfit, titanium plasma-sprayed implants (Restore) were utilized in the maxilla. At first-phase surgery, alloplastic bone substitute grafts (Bio-Oss, Geistlich Biomaterials, Wolhusen, Switzerland) with resorbable collagen membranes (Bio-Gide, Geistlich Biomaterials) were used when necessary. All implants were placed by the same clinician, who was experienced in periodontology and dental implantology. All of the patients received the same postsurgical instructions and medication. Following the protocol, the data related to pain during surgery was recorded. In addition, the duration of the surgical procedure, location and number of implants, use of grafts or membranes, and surgical complications were recorded at this stage.
• Phase III: 24 Hours after surgery.
  Immediate recording at 24 hours was selected to have an evaluation of all signs and symptoms at the possible peak. Same data was recorded as in phase I.
• Phase IV: 1 Week and 1, 2, and 3 months after surgery.
  The same parameters as in phase I were recorded on the Pain Data Sheet. A second measurement of maximal opening was taken at 1 week postsurgery to evaluate possible changes of maximum opening as a result of the surgical procedures. The evaluations at 1, 2, and 3 months were selected for observations of long-term postsurgical signs and symptoms.
• Phase V: Second-stage surgery.
  All patients underwent the secondphase surgical procedures The 4-month time selection corresponded to the second surgery for implants placed in the mandible and to the 6-month timing that corresponded with the second-stage surgery for implants placed in the maxilla. At the time of second-phase surgery, acellular dermal grafts (AlloDerm, LifeCell, Branchburg, NJ) were utilized when insufficient attached mucosa was present. All data were again recorded as in phase I.
• Phase VI: 1- and 2-Year follow up.
  All data were again recorded as in phase I. The times of observation at 1 and 2 years were selected to evaluate all of the signs and symptoms during a longer period of time, which would allow us to answer some questions (repeatedly asked by the patients) in relation to implant survival and possible long-term pain.

All of the collected data were processed for statistical analysis.